MEDICARE: VICKERS FAMILY DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1689238289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICKERS FAMILY DENTAL

Provider Business Mailing Address
First Line	:	PO BOX 11470
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77391-1470
Country	:	US
Telephone Number	:	281-440-1200
Fax Number	:	281-440-3578

Provider Business Practice Location Address
First Line	:	13810 CHAMPION FOREST DR STE 204
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77069-1868
Country	:	US
Telephone Number	:	281-440-1200
Fax Number	:	281-440-3578

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. STEPHANIE ANN VICKERS
Credential	:	RDA
Telephone Number	:	281-440-1200

Provider Enumeration Date	:	04/29/2019
Last Update Date	:	04/29/2019

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Directions to “VICKERS FAMILY DENTAL ” Practice Location

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